Overview
Definition:
A gastrostomy tube (G-tube) is a surgically placed tube through the abdominal wall into the stomach, providing a route for enteral nutrition, decompression, or medication administration
Percutaneous endoscopic gastrostomy (PEG) is the most common method of insertion
Regular tube changes are essential for maintaining patency, preventing infection, and ensuring patient comfort and efficacy of feeding.
Epidemiology:
Gastrostomy tubes are commonly placed in patients with dysphagia due to neurological conditions (stroke, ALS, dementia), head and neck cancers, or other conditions preventing adequate oral intake
Rates vary by age and indication, with increasing use in elderly and debilitated populations
PEG insertion accounts for the majority of gastrostomy placements.
Clinical Significance:
Proper management, including timely tube changes and prompt troubleshooting of issues, is crucial for preventing malnutrition, aspiration pneumonia, skin breakdown, and other complications
This topic is vital for surgical residents to ensure safe and effective patient care, especially during their DNB and NEET SS preparation.
Indications For Placement And Change
Indications For Placement:
Long-term enteral nutrition needs
Dysphagia secondary to neurological disorders
Gastric outlet obstruction
Esophageal strictures or fistulas
Gastric decompression
Administration of medications when oral route is not feasible.
Indications For Change:
Tube malfunction (blockage, leakage)
Signs of infection at the stoma site
Skin irritation or breakdown around the stoma
Accidental dislodgement or breakage of the tube
Routine scheduled replacement (e.g., annually for some types).
Types Of Tubes:
Foley catheter-type, low-profile devices (button), and larger bore tubes
Material (silicone, polyurethane) and design affect longevity and complication rates.
Gastrostomy Tube Change Procedure
Pre Procedure Assessment:
Review patient history and indication for G-tube
Assess stoma site for signs of infection or breakdown
Confirm tube size and type
Ensure adequate patient positioning and consent.
Equipment Preparation:
Sterile gloves, sterile gauze, antiseptic solution (e.g., chlorhexidine), lubricant (water-based), new gastrostomy tube of appropriate size and type, tape or fixation device, saline flush, syringe, and dressing supplies.
Step By Step Procedure:
Clean the stoma site thoroughly
Gently remove the old tube, potentially using a small amount of lubricant if resistance is felt
Irrigate the tract with saline
Insert the new tube, ensuring proper depth and fixation
Secure the tube with a fixation device or tape
Flush the new tube with saline to confirm patency
Dress the stoma site
Document the procedure.
Post Procedure Care:
Monitor the stoma site for bleeding, leakage, or signs of infection
Ensure the tube is patent by attempting to aspirate gastric contents or flush with saline
Resume feeding as per protocol
Educate patient and caregivers on stoma care and signs of complications.
Common Troubleshooting Issues
Tube Blockage:
Symptoms include inability to flush or administer feed/medication, decreased feed volume
Causes: thick formula, inadequate flushing, medication precipitates
Management: attempt gentle flushing with warm water, try declogging agents (e.g., pancreatic enzymes), repositioning tube
If persistent, may require tube replacement or endoscopic intervention.
Tube Leakage:
Leakage around the stoma site
Causes: improper tube fixation, stoma erosion, infection, tube dislodgement
Management: ensure tube is correctly positioned and secured, optimize skin care, treat any infection, consider tube replacement if leakage is significant or persistent.
Skin Irritation And Breakdown:
Redness, maceration, excoriation, or granulation tissue around the stoma
Causes: gastric secretions, friction, infection, allergic reaction to tube material or dressing
Management: meticulous stoma hygiene, barrier creams, repositioning tube, treating infection, using appropriate dressings, considering a low-profile device.
Pain At Stoma Site:
Can be due to infection, inflammation, or pressure
Management: assess for underlying cause, administer analgesics, optimize stoma care, ensure proper tube fit and fixation.
Tube Dislodgement:
Accidental removal of the tube
Management: Cover the stoma site with a dressing and immediately contact the medical team
Do not attempt to reinsert a tube without medical guidance, as this can cause further injury or create a false tract
A tract can close rapidly, necessitating urgent intervention.
Complications Of Gastrostomy Tubes
Early Complications:
Bleeding (at stoma site or internal), peritonitis (due to leakage or perforation), aspiration pneumonia, wound infection, pain, accidental dislodgement.
Late Complications:
Tube obstruction, leakage, stoma site infection, granulation tissue formation, skin ulceration, gastrocolic fistula, buried bumper syndrome (for PEG tubes), gastric outlet obstruction.
Prevention Strategies:
Strict aseptic technique during insertion and changes
Regular, adequate flushing of the tube
Appropriate enteral formula and administration technique
Good stoma hygiene and skin care
Patient and caregiver education
Prompt recognition and management of issues
Use of appropriate tube type and size.
Key Points
Exam Focus:
Indications for G-tube placement and change are frequently tested
Troubleshooting common issues like blockage and leakage is a high-yield concept
Understanding potential complications and their management is critical for DNB/NEET SS surgery exams.
Clinical Pearls:
Always confirm tube patency with saline flush after any manipulation
Gentle technique is paramount during tube changes to avoid tract injury
Never force a flush
Proactively educate patients and families on home care
Promptly assess any new stoma site pain or drainage.
Common Mistakes:
Failure to adequately flush the tube, leading to blockage
Aggressive flushing attempting to clear a blockage, risking perforation
Delayed recognition of tube dislodgement, allowing the tract to close
Inadequate stoma site care leading to infection or breakdown.